* name:


partner's name:

address:


Check here if this is an address change

city:

state:	zip code:

business telephone:


home telephone:


fax:


* email:

Yes! I want to be a member of Astraea. I will annually give:

$40 Basic Membership
$75 Household
$100
$250
$500

for

1 year
2 years
3 years
10 years
Other    years

Limited income membership $25

Yes! I want to join the Leadership Gift Circle. I will annually give:

$1,200
$2,500
$5,000
$10,000
$25,500

for

1 year
2 years
3 years
10 years
Other    years

This is a

new membership
renewal

I wish to pay in installments. My tax-deductible gift will be made in:

Monthly Installments of Quarterly Installments of Semi-annually Installments of

$ $ $

for an annual total of $

Please do not rent or exchange my name
I would like my donation to remain anonymous.

Please make my gift

in honor of:
in memory of:

name(s):


Please send an acknowledgement of this gift to:

name(s):


address:


city, state, zip code:

(no amount will be specified)